出版社：Utrecht University, Maastricht University, Groningen University
摘要：An introduction : (comprising context and problem statement) The community intervention team (CIT) required an ICT solution to support nurses treating patients in the community. There was no ICT connectivity between the hospital, the CIT and GPs. Short description of practice change implemented : An ICT solution was developed and implemented in house that ensured the CIT service had up-to-date accurate patient information delivered efficiently. Software installed on secure electronic devices, allows the nurse real time access to a patient’s summary record, and facilitates the recording of visit details while with the patient. Aim and theory of change : The aim was to support nursing teams in the community, and improve real-time communications between the hospital, CIT, GP and public health nurses (PHNs). Targeted population and stakeholders : The target population is a 480,278 catchment area covered by the CIT. Stakeholders include HSE management, hospital consultants, Directors of nursing, bed planners, discharge managers, PHN’s, GP’s and primary care teams (PCTs). Timeline : The development of the ICT platform was completed in conjunction with the implementation of the CIT service. An iterative approach was taken to the development of the software and configuration is enhanced when warranted through feedback provided by users. Highlights: (innovation, Impact and outcomes) Continuity of care is a central aspect for the CIT. Improved real-time communications underpinned by ICT now exist between all the stakeholders involved in the patient’s care. The CIT ICT platform is linked to GP surgeries, acute hospitals, out-of-hours service and public health nursing to facilitate the seamless and efficient flow of information. The Hospital can refer a CIT patient through a secure weblink form connecting the HSE network to the CIT network, while the GP can generate an electronic referral through their in house software using the National referral template, via the national messaging system, Healthlink. On discharge from the CIT, an electronically generated summary is sent to the GP, the hospital or the public health nurse (PHN) as appropriate. Comments on sustainability and transferability : The ICT platform is built on the core principle that it is scalable to increase capacity as required as well as facilitating interoperability and configurability as the service develops. Conclusions and Discussion: (comprising key findings) Productivity of the nurses is optimised as there in no unnecessary travel to the CIT hub to gather patient information. Response times to patients are improved as patients can be allocated to nurses based on their location. The ICT platform has operated successfully for over five years and has provided invaluable electronic links between all the consulting clinicians involved in a patient’s episode of care. The collaborative approach has ensured that the service is patient centred and the information reaches the right person at the right time. Existing record systems are undisturbed, but updated immediately. Lessons learned : ICT is a key building block to integrated care as it supports the clinician and the patient by facilitating the seamless secure transfer of information. In-house design has enabled local harmonisation.
